 |
|
 |
|
 |
 |
|
 |
 |
 |
 |
 |
 |
 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
PEDIATRICS Vol. 108 No. 2 August 2001, pp. 271-276
and
From the * Department of Pediatrics, Centre hospitalier de
l'Université Laval, and Objective. The objective of our study
was to collect data on the totality of recent skin injuries in normal
children and adolescents, and to determine the relationship between the
number of injuries, the age of the child, and the time of year in a
temperate climate.
Methods. The participants in this study were children and
adolescents seen successively for a reason other than trauma over a
period of 1 year, by the first author (J.L.), in a university medical center in Québec City, Canada. The total body surface, with the exception of the anal-genital area, was examined systematically. The
characteristics and location of all recent injuries (bruises, abrasions, scratches, cuts, burns, etc) were recorded. Scars from old
injuries were ignored. The statistical method used for comparison was
the Fisher's exact test.
Results. Two thousand forty examinations were done on 1467 youngsters from 0 to 17 years of age. Nine hundred thirty-one
examinations were done on boys and 1109 on girls. The majority of
children 9 months and older (76.6%) had at least 1 recent skin injury, without a significant difference between the sexes. Seventeen percent
of the total sample of children had at least 5 injuries, whereas 4%
had 10 or more, <1% had 15 or more, and 0.2% had 20 or more. The
sites involved were mostly the lower limbs. Less than 2% of the total
sample of children had injuries to the thorax, abdomen, pelvis, or
buttocks, and <1% to the chin, ears, or neck. The majority of
injuries observed were bruises, regardless of the time of year. There
were, however, more skin injuries during the summer and the proportion
of abrasions was higher at this time of the year. The 0- to 8-month age
group was unique from all points of view. Skin injuries were rare in
this age group (11.4%); they did not vary with the season, and they
were mainly on the head and the face. Their injuries were mostly
scratches. Bruises were found in only 1.2% of this group.
Conclusions. The majority of normal children (after
the age of 9 months) and adolescents, who do not consult for trauma,
had 1 or more recent skin injuries. These injuries, mostly bruises, are
more prevalent in the summer in a region with a temperate climate and can be present on all parts of the body, although they are most frequently observed on the limbs, especially on the shins and knees.
Even if there are no recognizable marks on the skin, physicians must
pay particular attention to children who have injuries with other
unusual characteristics (uncommon location, Québec Department of Public
Health, Québec, Canada.
ABSTRACT
Top
Abstract
Methods
Results
Discussion
Conclusion
References
15 injuries, bruises in a
child <9 months of age, numerous injuries elsewhere than the lower
limbs, numerous injuries in the cold seasons in a temperate climate,
injuries other than bruises, abrasions or scratches) because they could
be a sign of a bleeding disorder or physical abuse.bruising, child abuse, accidental injury.
Skin injuries are the most common and the most easily
recognizable signs of abuse in children.1 Up to 90% of
victims of physical abuse present skin injuries.2 Only 8%
of these injuries are pathognomonic because of their shape
(recognizable imprints).3 In the other cases, the
physician must rely on the other characteristics of the injuries and on
other elements to identify physical abuse: delay in consulting,
injuries incompatible with the history or the developmental stage,
association with specific injuries in other systems (eg, classical
metaphyseal fractures, extensive retinal hemorrhages, subdural
hematomas), suspicious attitude of the parents, absence of symptoms or
signs of a medical condition that could cause the observed injuries, etc.
Although severe physical abuse has a greater chance of being
identified, minor physical abuse is more difficult to distinguish from
accidental injury. The most difficult situation is when the physician
observes recent skin injuries in a child who is not consulting for
trauma. Could these be signs of physical abuse or, on the contrary, are
these injuries a result of normal physical activity in children? This
question is important because the severity of physical abuse often
increases with time and the physician could contribute to prevention by
reporting the situation.4 On the other hand, reporting
innocent parents can have regrettable consequences for them.
Studies conducted in victims of physical abuse and accidents led to the
identification of certain characteristics of injuries that, although
not specific, facilitate their distinction, especially with regards to
their site.5-8 Few studies, however, were devoted to skin
injuries in "normal"
children.a At the time our study
was conducted, the authors could find only 5 articles in the literature
between 1977 and 1997.9-13 Since then, 2 other studies
have been published.14,15 However, as seen in Table
1, despite their usefulness, they do not
give an overall view of skin injuries in normal children, either
because they are comprised of a small cohort of children, they only
concentrate on a particular age group, or they are interested in
bruises only. Few data are available on the absolute number of skin
injuries in normal children. Wedgwood13 reported a mean of
5 bruises in children <4 years old who could walk and who could also
climb stairs. Sugar et al15 described up to 11 bruises in
children <3 years old who could walk.
TABLE 1
Studies Previously Published on Recent Skin Injuries in Normal Children
Our study was conducted to obtain data on skin injuries in normal children, as well as in normal adolescents, and to bring to light aspects that have not been treated previously, notably the relationship between the number of skin injuries according to the age of the child and the time of year in a temperate climate.
| |
METHODS |
|---|
|
Top
Abstract
Methods
Results
Discussion
Conclusion
References
|
|---|
Design and Population Studied
The study was conducted over a period of 1 year
between July
15, 1997, and July 14, 1998. The study participants were all children
and adolescents (from birth to 17 years old) consecutively examined by
the first author (J.L.) during this period at the outpatient clinic and
at the medical section of the emergency department of the Centre
hospitalier de l'Université Laval, where this author practiced
general pediatrics part-time. The examiner has 25 years of experience
as a consultant in child abuse cases. Québec City is located in
Canada in a temperate climate with 4 seasons, including a particularly
rigorous winter. All of the youngsters seen in consultation for a
reason other than trauma were admissible to participate in the study if
they did not have 1 of the following criteria for exclusion: neurologic
problems that prevent independent mobility; generalized skin problems
that prevent an adequate evaluation of skin injuries; a medical
condition or medication associated with easy bruising; unstable
condition; and suspicion of physical abuse. The suspicion of physical
abuse was based on their characteristics (recognizable imprints),
history incongruous or implausible with the injuries, lesions
incompatible with child's development, or the observation of a
pathologic parent-child interaction. Because consecutive visits to the
doctor were involved, the same child could participate in the study
more than once. As bruises can take up to 1 month to disappear, each
visit for the same child at an interval of <1 month was excluded from
the study to avoid counting the same injuries more than once.
The following data were collected during each visit: age of the child, sex, race, personal and familial history of medical conditions that could affect coagulation, and medication. An explanation was sought for all injuries (cause, circumstances, time). After obtaining parental authorization or consent from adolescents 14 years and older, the author proceeded with a visual examination of the skin over the entire body surface (including buttocks), with the exception of the anal-genital region. This examination was incorporated into the complete examination done during the visit. The anal-genital region was not examined systematically for fear of refusals to participate in the study, particularly among school-aged children and adolescents. The characteristics (size, color, aspect, location) of all skin injuries were recorded on a printed body diagram. Scars from old injuries were ignored. A predominance of girls in the study was foreseeable because of the fact that the first author held a clinic for urinary tract infections and this pathology is more prevalent in girls after their first year. Blood tests (complete blood count, coagulation tests) were not performed systematically, but they were requested if needed, according to the clinical situation.
In total, the first author made 2389 encounters with children and adolescents during the period of the study. Two hundred fifty-three of these youngsters had already been seen less than a month before and were already registered in the study. Twenty-nine had a major neurologic handicap. Physical abuse was suspected in 23 cases. The unstable condition of 19 children was not conducive to a complete examination of the skin. Nine children had vasculitis or a coagulation problem. Eight children had a generalized skin problem that made it difficult to evaluate soft-tissue injuries. In 7 children, 1 of the reasons for consultation was trauma. One child was brought to see the doctor for easy bruising. All of these cases, 349 in total, were excluded from the study. There were no refusals to participate in the study.
Statistical Analysis
Statistical analysis of data were performed using the Fisher's exact test to compare different proportions. The software Statistical Analysis System for Windows Release 6-12 (SAS Institute Inc, Cary, NC) was used. Statistical significance was set at 0.05.
Definitions
A basic definition of physical abuse is the nonaccidental injury of a child inflicted by a caregiver. This includes corporal punishment that results in injuries. Recent injuries to the skin were classified in the following manner:
Bruises (ecchymoses, contusions, hematomas): escape of blood into the skin or subcutaneous tissue, or both, following the rupture of blood vessels, usually capillaries, by the application of a blunt force.
Abrasion: skin injury caused by a tangential impact, bringing about a separation or an excision of small superficial skin fragments.
Scratch (scrape): wound resulting from light tearing of the skin.
Others: all other recent injuries to the skin (cuts, bites, burns, etc).
| |
RESULTS |
|---|
|
Top
Abstract
Methods
Results
Discussion
Conclusion
References
|
|---|
Sampling
A total of 1467 youngsters (719 boys and 748 girls) were included in the study for a total of 2040 examinations. One thousand one hundred thirty-two were examined only once, 188 twice, and 84 on 3 occasions. Forty-two, 14, and 7 children were seen on 4, 5, and 6 occasions, respectively. For the purpose of the study, each encounter with the examiner contributed 1 data point each to the whole study sample. The results are described as 2040 different physical examinations during a year.
There were 931 visits for boys and 1109 for girls. The majority of the visits, that is 1912 or 93.7%, were by white children. The others were divided up as follows: 96 for children of Asian origin (4.7%), 30 for black children (1.5%), and 2 for Amerindian children (0.2%). One thousand four hundred fifty-one examinations (71.1%) were done at the outpatient clinic by appointment (general pediatrics, urinary tract infection clinic), and 589 (28.9%) at the medical section of the emergency department. One thousand one hundred forty-five visits (56.3%) were by children already known to the examiner. For reasons of comparison, the patients studied were divided into 4 age groups: 0 to 8 months, 9 months to 4 years, 5 to 9 years, and 10 to 17 years. The category 0 to 8 months was preferred rather than the usual classification of 0 to 11 months because many infants become independently mobile from the age of 9 months and this has been shown to have a clear influence on skin injuries.14,15
Number of Injuries by Age and Sex
Table 2 shows the percentage of all children with skin injuries by age and sex. It also indicates the number of injuries in each of the categories. No significant difference was found between boys and girls regarding the number of injuries, regardless of the age group. In the study population, 2040 patients had a total of 5686 recent skin injuries. Considering only those children and adolescents who had injuries, the mean number of lesions was 1.3 in the 0- to 8-month age group (range: 1-3), 3.9 in the 9-months to 4-years age group (range: 1-39), 4.5 in the 5- to 9-years age group (range: 1-21), and 3.6 in the 10- to 17-years age group (range: 1-12). The 0- to 8-month age group was clearly unique from all the other age groups because of the few injuries observed. The majority of these infants (88.6%) did not have any skin injuries. Among those who had injuries (11.4%), no child had >3. In the other age groups, including the adolescents, the majority of youngsters (76.6%) had at least 1 skin injury. Children 5 to 9 years old are the most susceptible to having at least 1 injury (87.2%). It is also this group that has the largest number of injuries. In fact, 32.6% of the children in this group had 5 or more injuries as compared with 19.6% for the group 9 months to 4 years and 19.7% for the group of 10- to 17-year-olds. Four percent of the total sample of children and adolescents had 10 or more injuries and <1% had 15 or more. Only 4 children (0.2% of the total sample) had 20 or more injuries.
|
Site of Injuries
The body sites affected by skin injuries are listed by order of frequency in Table 3. Although half of all of the children seen had at least 1 injury on the legs (the vast majority on the shins), <2% of the entire group of children presented injuries to the thorax, abdomen, pelvis, or buttocks and <1% to the chin, ears, or neck. Table 4 provides more details on the sites of injuries with regards to the sex and the age of the children. No significant difference was found between the sexes of children with regards to the sites of the injuries. It is a different story for age. The 0- to 8-month age group distinguishes itself clearly from the other age groups by a predominance of injuries to the head and to the face rather than to the limbs. The group of 5- to 9-year-olds presents the greatest number of injuries and has the highest proportion of sites implicated. For example, 3.6% of the children in this group had injuries to the buttocks and 3.9% to the lumbar region. The group of 10- to 17-year-olds distinguishes itself from the other groups by a quasi absence of injuries to the head and to the face.
|
|
Types of Injuries
Table 5 indicates the percentage of children that present each type of injury in the different age groups. Globally, bruises are the injuries that were by far the most frequently seen, except in the group 0 to 8 months where scratches predominated. This latter group was also unique by the low proportion of children with bruises or abrasions (1.2%). The group of 5- to 9-year-olds had the largest proportion of children presenting all of the types of skin injuries. Eighty percent of the children in this age group had at least 1 bruise. Skin injuries other than bruises, abrasions, and scratches (cuts, bites, burns, etc) were seen in only 1.9% of the total sample of children and adolescents.
|
Time of Year
The influence of the time of the year was apparent with regards to the number and type of lesions. Table 6 illustrates the relationship between multiple injuries and the time of the year in each age group. There was a significant difference between the warm seasons and the cold seasons. The percentage of children with 5 or more injuries was 18% in the fall and 12% in the winter. This percentage increased to 25% and 33% in the spring and in the summer, respectively. All of the age groups follow this tendency, except for the 0 to 8 months group. In this latter category, the number of injuries did not vary with the time of year, and no child had >3 injuries.
|
Figure 1 illustrates the different types of injuries according to the time of year. Although bruises clearly predominated throughout the year, a significant variation was noted in the number of abrasions and scrapes according to the time of year. The percentages of these 2 types of injuries were higher during the summer.
|
Exceptional Cases
The 4 children with 20 or more injuries were all seen in the warm seasons: 2 in the spring and 2 in the summer. A 3-year-old boy had 20 skin injuries (1 scratch, 1 abrasion, and 18 bruises). His lesions were distributed as follows: 2 on the face, 2 in the lumbar region, 8 on the upper limbs, and 8 on the lower limbs. A 6-year-old girl had 20 skin injuries (10 abrasions and 10 bruises). Her lesions were distributed as follows: 4 on the upper limbs and 16 on the lower limbs. Twenty-one skin injuries (9 scratches, 4 abrasions, and 8 bruises) were found in a 7-year-old girl. The distribution of her lesions was as follows: 1 on the face, 4 on the upper limbs, and 16 on the lower limbs. A 4-year-old girl had 39 skin injuries (2 scratches and 37 bruises). Her lesions were distributed as follows: 1 on the posterior thorax, 1 in the lumbar region, 4 on the upper limbs, and 33 on the lower limbs. A total of 100 skin injuries were found in these 4 exceptional cases. Seventy-two of these injuries were located on the lower limbs. A more extensive medical and social evaluation of these cases did not reveal a medical problem or physical abuse.
| |
DISCUSSION |
|---|
|
Top
Abstract
Methods
Results
Discussion
Conclusion
References
|
|---|
Our study is the first, to our knowledge, that covers the period of childhood and adolescence for the totality of recent skin injuries in normal children and that also takes into account the time of year. Our results are concordant with previously published studies, but they also provide additional information. The first element to note is that after the age of 9 months, whatever the reason for consultation, a doctor is likely to find at least 1 recent skin injury in 3 out of 4 children. Only 2 studies not confined to very young children are available for comparison. In their study, Roberton et al11 found that 50% of children between the age of 10 months and 11 years had at least 1 soft tissue injury. Pascoe et al9 indicated that 73% of their patients from 1 to 12 years of age had soft tissue injuries on the anterior legs. Normal ambulatory children may have multiple recent skin injuries and some may have even have 20 or more. There is no difference between boys and girls with respect to the frequency of injuries, but age makes a difference. Five- to 9-year-olds have the most injuries. In a temperate climate like that of Québec City, the time of year has an influence on the frequency and type of injuries. Children have more injuries during the warm seasons, which is not surprising because they go outside more often and they wear less clothing that can protect them from falls and accidental injuries. Although bruises are the most common type of injuries in all seasons, a higher proportion of abrasions and scrapes can be found in the summer.
As indicated in all previous studies, the most predominant sites for skin injuries in normal children after the age of 9 months are bony prominences of the limbs: shins, knees, elbows, forearms.9,11,13,15 Concerning the bony prominences of the face, the forehead is not a rare location for injury (6.4%) between 9 months and 4 years. This is a finding similar to Sugar et al15 (5.7%) in their study of toddlers. Certain sites are rarely affected in normal children, whereas they are frequently affected in children who are victims of physical abuse (ears, neck, buttocks, the back or lumbar regions).5-7 Cheeks are usually considered to be a location suspect for physical abuse. We found that 3.2% of infants <8 months old and 4.5% of toddlers had an injury at this site. In our study, there was no difference between boys and girls with regards to the sites of injuries. However, injuries to the head and the face, already rare, were exceptionally seen in adolescence.
As reported by several authors before us, children in the 0- to 8-month age group are different from older children from all points of view.11-15 This is not surprising because normal children hurt themselves by falling and by hitting themselves, which requires that they be independently mobile. Here, it is not a simple question of age that is the cause, but rather the stage of development. Bruises are not seen in children before they start crawling. This explains why this type of injury is rarely seen before the age of 9 months.12,14,15 Contrary to other age groups, there is no variation in the number and the type of injury in function of the time of year in the 0- to 8-month group. Moreover, injuries in this group are mainly found on the head and the face, and they are most often scratches that the infants make themselves with their fingernails. In our study, none of the 246 children from 0 to 8 months had >3 injuries at a time. The results of a descriptive study such as ours are foreseeable, and therefore its usefulness may be questioned. However, in our opinion, precise data on skin injuries in normal children in different age groups and different situations will help physicians detect real situations of abuse and thus avoid unfounded reports to child protection agencies. From a medicolegal perspective in cases involving skin injuries without adequate explanations, our results could help to persuade a judge of their unusual features (number, location, etc).
Our study has its limits. There was no systematic effort to make sure that the children participating in the study were representative of the general population of children in the Québec City area. The fact that 56.3% of the children were already known to the examiner may have affected their social-class distribution (our hospital is located in a middle-class neighborhood). The children in our study were overwhelmingly white. We cannot infer that our data are applicable to children of other races. The anal-genital region was not examined systematically in all children. Other studies showed the rarity of accidental injuries in this region.9,11 It is impossible to assert that none of the injuries observed in these normal children were attributable to a medical condition that causes easy bruising because blood tests were not performed systematically in all children. Some of these injuries could also have been of an abusive nature and escaped the attention of the examiner. It is probable, however, that these situations are rare and that they do not interfere with the results presented.
| |
CONCLUSION |
|---|
|
Top
Abstract
Methods
Results
Discussion
Conclusion
References
|
|---|
To avoid an unnecessary climate of suspicion, it is
important to take into consideration the fact that most normal children have injuries on their bodies once they begin walking. Individually, 20 or more injuries can be found. Although the lesions are most often
found on the lower limbs, no site is spared. Thus, the number of
injuries or their site does not allow us to reach a conclusion on their
origin. Each case is one of a kind. Although certain sites are more
frequently affected in cases of abuse, site is not a pathognomonic
characteristic in itself. Similarly, injuries in sites more common to
accidents can be of an abusive origin. Therefore, the whole picture
must always be considered (type and shape of the injuries, location,
age, developmental stage, time of the year, injuries of other systems,
explanations about the injuries, attitudes of the parents and the
child, etc) before passing judgment. Recognizable imprints speak for
themselves. In the absence of these pathognomonic signs, the physician
must pay particular attention to children who present injuries with other unusual characteristics (uncommon location, 15 injuries, bruises in a child <9 months of age, numerous injuries elsewhere than
the lower limbs, numerous injuries in the cold seasons in a temperate
climate, injuries other than bruises, abrasions or scratches) because
they could signify a bleeding disorder16 or physical
abuse.
| |
FOOTNOTES |
|---|
a In this article, "normal" signifies children who are not victims of physical abuse and who do not have any known medical condition that can easily cause bleeding.
Received for publication May 18, 2000; accepted Nov 16, 2000.
Reprint requests to (J.L.) 2705 Laurier Blvd, Sainte-Foy, Québec, Canada G1V 4G2. E-mail: jean.labbe{at}ssss.gouv.qc.ca
| |
REFERENCES |
|---|
|
Top
Abstract
Methods
Results
Discussion
Conclusion
References
|
|---|
This article has been cited by other articles:
 |
|
 |
|
  M. L. Peters, S. P. Starling, M. L. Barnes-Eley, and K. W. Heisler The Presence of Bruising Associated With Fractures Arch Pediatr Adolesc Med, September 1, 2008; 162(9): 877 - 881. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S Maguire, M K Mann, J Sibert, and A Kemp Are there patterns of bruising in childhood which are diagnostic or suggestive of abuse? A systematic review Arch. Dis. Child., February 1, 2005; 90(2): 182 - 186. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
E. Vogeley, M. C. Pierce, and G. Bertocci Experience With Wood Lamp Illumination and Digital Photography in the Documentation of Bruises on Human Skin Arch Pediatr Adolesc Med, March 1, 2002; 156(3): 265 - 268. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
 |
||
|
||
Home | My Pediatrics | Journal Information | Current Issue | Past Issues | Subscriptions & Services | Contact Us Click here for faster international access © 2001 American Academy of Pediatrics. All rights reserved. |
||
|
||
